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Erectile Dysfunction:
A Patient Quick-Guide to
Cause, Diagnosis & Treatment
Ronald W. Lewis, MD
Chief of Urology, Medical College of Georgia
Editor-In-Chief
Table of Contents
Introduction................................................................................... 1
The Erection Process................................................................... 2
Underlying Causes of ED........................................................... 4
Your First Physician Visit............................................................ 7
Questions to Ask.................................................................... 7
Common Tests........................................................................ 8
Current Costs for ED Treatments...........................................10
Current Treatments for ED.......................................................10
Additional Resources................................................................15
Published in the USA by
Charter Publishing Company
Post Office Box 1447
Augusta, GA 30901
Copyright © 2006 Charter Publishing
Library of Congress Cataloging-in-Publication Data
No part of this book may be reproduced in any form without written permission from
the publishers, except for the quotation of brief passages for the purpose of review.
Introduction
Erectile Dysfunction or ED, sometimes referred to as impotence, is
defined as the repeated inability to achieve or sustain an erection
sufficient for sexual intercourse. Population and lifestyle changes in
America are resulting in greater numbers of older citizens – and greater
numbers of younger ones – with health factors that lead to ED.
There are three principal factors that lead to ED. Psychological factors
range from depression to stress and self-esteem. Physical factors range
from trauma (surgery or injury), to diseases (diabetes, cardiovascular
disease). The third factor can be use or abuse of substances ranging
from prescription and over the counter drugs to illegal substances.
These factors can easily interrupt the delicate process of mental,
nervous and vascular systems that have to work together to produce an
erection. For this reason alone, ED should be regarded as an important
signal that other, more serious health problems may be present.
Everyone with ED should understand that the problem is treatable.
Even if underlying causes, such as diabetes, cannot be cured, the ED can
be treated. Treatment can range from counseling to inexpensive and
non-invasive methods – and even more extreme and highly invasive
options that may prove right for some people.
The purpose of this booklet is to provide the patient with a brief
overview of how the erectile process works, the psychological and
physical causes of the problem, and the current treatments that are
available in order of invasiveness. Also provided are guidelines on
what to ask your physician, what kind of testing is typical for ED, and
how your choices of treatment should be explained to you.
Ronald W. Lewis MD
ED: A Patient Quick-Guide to Cause, Diagnosis & Treatment – 1
THE ERECTION PROCESS
To understand what causes erectile dysfunction or ED, it is important
to first review how an erection occurs. For a man to have an erection, a
complex process takes place within the body.
An erection involves the central nervous system, the peripheral
nervous system, psychological and stress-related factors, local factors
with the erection chambers (corpora cavernosa) or the penis itself, as
well as hormonal and vascular components.
The penile portion of the process leading to an erection represents
only a single component of a very complicated and complex process.
Erections occur in response to touch, smell, auditory and visual stimuli
that trigger pathways in the brain.
Information travels from the brain to the nerve centers at the base
of the spine, where primary nerve fibers connect to the penis and
regulate blood flow during erections and afterward.
Sexual stimulation causes the release of chemicals from the nerve
endings in the penis that trigger a series of events that ultimately cause
muscle relaxation in the corpus cavernosum.The smooth muscle in the
corpus cavernosum controls the flow of blood into the penis. When the
smooth muscle relaxes, the blood flow dramatically increases, and the
spongy tissue within the corpus cavernosum become full and rigid,
resulting in an erection. Venous drainage channels are compressed
and close off as the erection bodies enlarge.
Detumescence (the process by which the penis becomes flaccid)
results when muscle-relaxing chemicals are no longer released, or
other chemicals are released to constrict the muscle again.
Natural erection function is a reflex action that occurs without a great
deal of planning or effort. When the natural erection process fails, a nonnatural process may take its place including the use of pharmaceuticals
or medically approved devices. In other words, a couple must be the
driving force for functionality to replace the natural reflex action.
2 – ED: A Patient Quick-Guide to Cause, Diagnosis & Treatment
Male Reproductive System
Cross Section of the Penis
Side View of the
Penis When Erect
Side View of the
Penis When Flaccid
ED: A Patient Quick-Guide to Cause, Diagnosis & Treatment – 3
UNDERLYING CAUSES OF ED
There are many underlying causes of erectile dysfunction. The creation
of an erection is a highly complex process involving psychological
impulses or mental stimulation from the brain, adequate levels of
the male sex hormone testosterone, a healthy nervous system, and
adequate and healthy vascular tissue in the penis. A wide range of
conditions and diseases impacting our psychological and physical
health can impact this process and cause ED. Often erectile dysfunction
is a sign of a more serious problem – for example, 12% of males
diagnosed with Diabetes Mellitus discover the disease following visits
to their physician for ED treatment1.
Approximately 80% of cases of ED diagnosed today have an organic or
physical origin. Here are some of the most common organic causes:
Smoking or Tobacco Use
Researchers have yet to establish a direct link between tobacco use and
ED, but the general consensus is that it will be found and that available
evidence links tobacco use with endothelial disease (endothelial cells
line the interior of blood vessels), which is linked to ED. Surveys of men
reporting ED show that significant numbers were smokers and the
conclusion is that tobacco use is an important risk factor for ED2.
Hormonal or Endocrine Issues
The endocrine system is a series of organs in the body that produce
hormones that control or regulate various bodily functions. The testes
within the scrotum, for example, produce testosterone, a hormone
that regulates sex drive or libido (other organs also produce similar
hormones called androgens). Not all erections require adequate levels
of testosterone. Hypogonadism is also a condition that leads to ED as
a result of reduced secretion of hormones needed for sexual function.
Hyperprolactinemia is another endocrine system issue involving the
pituitary gland that affects sexual function in a small number of men.
4 – ED: A Patient Quick-Guide to Cause, Diagnosis & Treatment
Diabetes Mellitus
Diabetes Mellitus is the inability of the body (actually part of the
endocrine system) to produce insulin that is needed to process sugar
in the bloodstream and tissues. High levels of sugar in the bloodstream
and tissues lead to damage of the nerve and vascular systems, both
of which are needed for healthy erectile function. At least 50% of
men with diabetes mellitus eventually develop erectile dysfunction,
often at an earlier age than men without the disease3. As mentioned
above, all too often ED may be the first sign of Diabetes in as many
as 12% of men with the disease. Diabetic neuropathy, damage to the
peripheral nerves of the arms, legs for example, can also involve the
sexual organs, resulting in ED. Damage to the large blood vessels in
older males can have the same effect, and poorly controlled diabetes
will also lead to damage of the smaller blood vessels, again impacting
sexual function.
Cardiovascular Disease and Hypertension
Many cases of erectile dysfunction can be related to vascular disease.
Arterial problems such as systemic or peripheral vascular disease
affect the blood vessels of the penis in the same way that other blood
vessels of the body are affected. As with Diabetes, ED is often the first
sign of more serious problems ranging from hypertension and heart
disease to arteriosclerosis4. High levels of cholesterol (especially with
low levels of HDL -‘good’ cholesterol5) and high blood pressure are
also risk factors for ED6. Venous leakage is a vascular problem specific
to the veins within the spongy tissue of the penis (corpus cavernosa).
As this tissue expands during the process of erection, the veins are
compressed and this maintains the erection. If the veins do not close
completely, leakage results and the erection cannot be maintained.
Surgery and Trauma
It is well established that ED is common after removal of the prostate
(radical prostatectomy), often the consequence of cancer of the
prostate. One study reports that about 60% of men undergoing the
ED: A Patient Quick-Guide to Cause, Diagnosis & Treatment – 5
operation, even nerve-sparing prostatectomy, have ED following
surgery7. The problem is less pronounced in younger males and in
those males with strong erectile activity before surgery8. Radiation
therapy (an alternative to prostatectomy) to the pelvic area is also a
source of damage to nerves involving erectile function9. Enlargement
of the prostate (benign prostatic hyperplasia), and its treatments do
not impact sexual function10.
Medications and Recreational Drugs
There is a significant connection between ED and prescription
drugs11, and more than 200 have been identified as having some
impact on erectile function12 (as listed below). Recreational drugs,
such as alcohol, marijuana, codeine and heroin, have also been shown
to be risk factors for ED13.
Psychiatric/Psychological Risk Factors
Today, it is thought that some 20% of cases of ED have a psychological origin. Occasionally ED will result from stress14, anxiety, depression
and post traumatic stress.
6 – ED: A Patient Quick-Guide to Cause, Diagnosis & Treatment
YOUR FIRST PHYSICIAN VISIT
The first physcian to discuss ED with is the physcian who knows the
most about your medical history. He or she is often the one treating
you for the disorder that caused your ED.
First: Ask Questions
Every patient should be prepared to discuss his ED problem with
his physician frankly and with the intention of receiving as much
information as possible about both the causes of the condition and the
range of treatments available. Some physicians may be uncomfortable
discussing sexual matters, or may perhaps be interested only in
suggesting one of the many treatments available. This is why it is
important to ask questions and seek a full explanation of both the
possible causes of your ED as well as the treatments available. If your
physician is a GP, he or she may refer you to a Urologist or sexual
medicine specialist, the specialists who most often deal with ED and
its treatment.
Questions to Ask Yourself Before Your First Visit
• Is sexual intimacy an important part of my relationship?
• Are my partner and I motivated to find a solution?
• Is abstinence or non-sexuality a viable and an accepted option
for ED?
• Are there any other non-erection related solutions?
Questions You May Want to Ask the Doctor
• What are the likely factors contributing to my ED?
• How serious is my disorder?
• What methods of treatment are available and/or recommended?
• What is the least invasive and most conservative treatment?
• What are the benefits of the recommended and alternative
treatments?
• What are the risks or complications of the recommended and
alternative treatments?
• Are there discomforts associated with the treatments?
• What methods will be used to prevent or relieve these discomforts?
• What are the side effects of the treatment?
ED: A Patient Quick-Guide to Cause, Diagnosis & Treatment – 7
• What impact will treatment, or not having treatment, have on
my normal functions and activities?
• How much does the treatment cost?
Common Tests
There are a number of common tests used to diagnose organic ED.
Some, or a combination of these tests may be used by your physician
or specialist:
CBC — Complete blood count (CBC) of red cells and white cells is used
to evaluate the presence of anemia. Other tests include serum lipids
and serum hormones.
Urinalysis — Urine is analyzed for protein (albumin), sugar (glucose),
and hormone (testosterone) levels that may indicate diabetes mellitus,
kidney dysfunction, and testosterone deficiency.
Liver and kidney function tests — Liver and kidney disease can
create hormonal imbalances.
Thyroid function tests — Thyroid hormones regulate metabolism and
the production of sex hormones; a deficiency may contribute to ED.
Erectile Function Tests
Tests that assess erectile function examine the blood vessels, nerves,
muscles, and other tissues of the penis and pelvic region.
Duplex ultrasound — Duplex
ultrasound is
used to evaluate
blood flow, venous leak, signs of
atherosclerosis, and scarring or
calcification of erectile tissue.
Examples of ultrasound scans.
8 – ED: A Patient Quick-Guide to Cause, Diagnosis & Treatment
ED: A Patient Quick-Guide to Cause , Diagnosis & Treatment
Rigidity Measurement – Rigidity or
strength of erections can be measured by a
measurement
– Rigidityand
or
numberRigidity
of devices.
The most modern
strength
of
erections
can
be
measured
by
accurate device is the Digital Inflection
a number
ofwhich
devices.
The mostpressure
modern
Rigidometer
(DIR)
measures
and accurate device is the Digital Inflection
inside the penis from contact with the
Rigidometer (DIR) which measures
glans or
tip. inside the penis from contact
pressure
Penile with
nerve
such as the
thefunction—Tests
glans or tip.
bulbocavernosus reflex test are used to
Penile nerve function – Tests such as
Digital
Inflection
determine
if there is sufficient
nerve
Digital
Inflection
the bulbocavernosus
reflex test are
used
Rigidometer
(DIR)
Rigidometer
(DIR)
sensation
in the penis.
to determine
if there is sufficient nerve
Nocturnal
penile
(NPT)—
sensation
in thetumescence
penis.
There Nocturnal
are two methods
for measuring
penile tumescence
(NPT)
changes
in
penile
rigidity
and
circumfer– There are two methods for measuring
ence during
nocturnal
erection:
gauge
changes
in penile
rigidity snap
and circumference
during nocturnal erection: snap
and strain
gauge.
gauge
and
strainwrapping
gauge.
Rigiscan Device
Snap gauge involves
three plastic
bands Snap
of varying
around three
the
gauge – strength
Involves wrapping
plastic bands
of varying
strength
around
penis. Erectile
function
is assessed
according
Rigiscan device
the
penis.
Erectile
function
is
assessed
to which bands break.
according
which bands
break. which
Rigiscan
is a toportable
device
Rigiscan
– A or
portable
deviceduring
which
measures
nocturnal
night time
measures
nocturnal
erections
with
two
sleep erections with two pressure loops
pressure
loops
thethe
tip
attached
around
theattached
tip andaround
base of
Penile Injections
and base of the penis.
penis.
Penile Penile
biothesiometry—This
useselectromagnetic vibration to
biothesiometry – Thistest
test uses
evaluate sensitivity
and nerve
function in the glands and shaft of the
electromagnetic
vibration
to evaluate
penis.
sensitivity and nerve function in the
glands Vasoactive
and shaft of
the penis.
injection
– When injected into the penis, certain solutions
cause injection—When
erection by dilating blood
vessels
in erectile tissue. Sometimes
Vasoactive
injected
into
during
this
procedure,
penile
pressure
is
measured.
the penis, certain solutions cause erection by
Injections into the penile tissue
dilating blood vessels in erectile tissue. can create erections and enable
Sometimes during
this procedure,
penile
further
diagnosis. – 9
ED: A Patient
Quick-Guide to
Cause, Diagnosis
& Treatment
pressure is measured.
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CURRENT TREATMENT & COSTS
(In order of invasiveness)
Psychotherapy – Vacuum Therapy – Oral Pharmaceuticals – Self Injections – Urethral Suppositories –
Penile Implant Surgery – Several Thousand
$150 – $650 (one time cost)
(additional tension systems when needed)
$1,700/ year on average
$2,400/ year on average
$2,300/ year on average
$5,000 – $20,000
PSYCHOTHERAPY
It was once thought that most cases of ED were purely psychological.
Today we know that more than 80% of cases are organic or physical in
nature and that only a small percentage of cases can be truly attributed
to psychological causes.
Psychological causes require counseling or sex therapy. This process
can take weeks or months. Some typical causes are anxiety (particularly
when a component of Post Traumatic Stress Disorder), depression,
guilt, indifference, low self-esteem, and stress. Very often, psychological
causes of ED are also associated with physical causes. Even ED resulting
from a purely organic cause will have a psychological impact on the
patient.
VACUUM THERAPY SYSTEMS
Vacuum therapy systems work by manually creating an erection. The
use of medically approved vacuum therapy systems have an efficacy
rate of over 90% and offer the safest, most conservative, non-invasive
option available for the treatment of erectile dysfunction.
10 – ED: A Patient Quick-Guide to Cause, Diagnosis & Treatment
The penis is inserted into a negative pressure
chamber, which is pressed against the body
to form a seal. A hand or battery activated
negative pressure device attached to the
negative pressure cylinder is used to create
a vacuum that draws blood into the penis,
causing the penis to become engorged.
After 1 to 3 minutes in the vacuum, an
adequate erection is created. Prior to the
penis being removed from the negative
pressure chamber, a tension system is placed
around the base of the penis to maintain the
erection until removed. Tension systems can
be left in place for 25 to 30 minutes.
Vacuum Therapy System
in Use.
As with any physical aid, practice is the key
to success when using vacuum therapy.
Once the patient has been trained on and
practiced with the system, the patient should Tension Systems Maintain
the Erection.
be able to produce a functional erection in
approximately 90 seconds. Vacuum therapy
systems are routinely covered by Medicare as well as many other private
insurance and managed care policies. A patient’s actual cost may be under
$100.00.
Vacuum therapy systems are also excellent to determine patient and
partner motivation to test for sexual function without the risks and costs of
more invasive treatments. Many physicians find that patients committed
to deploying the correct use of vacuum therapy are good candidates for
more invasive pharmaceutical or surgical treatments. Also, vacuum therapy
is the only treatment that is effective when used in conjunction with all
other treatments.
Possible Side Effects:
Temporary bruising (if not used correctly), Excessive rigidity
ED: A Patient Quick-Guide to Cause, Diagnosis & Treatment – 11
ORAL MEDICATION
Oral medications used to treat erectile
dysfunction include selective enzyme
inhibitors sildenafil, vardenafil HCl, and
tadalafil.
Selective enzyme inhibitors are
available by prescription and may be
There are three types
taken up to once a day to treat ED. They
of oral ED medications.
improve partial erections by inhibiting
the enzyme that facilitates their reduction and increase levels of cyclic
guanosine monophosphate (cGMP, a chemical factor in metabolism),
which causes the smooth muscles of the penis to relax, enabling blood to
flow into the corpora cavernosa.
Patients taking nitrate drugs (used to treat chest pain) should not take
selective enzyme inhibitors. There are precautions for customers using
alpha blockers.
Men who have had a heart attack or stroke within the past 6 months
and those with certain medical conditions (e.g., uncontrolled high blood
pressure, severe low blood pressure or liver disease, unstable angina) that
make sexual activity inadvisable should not take oral medications. Dosages
of the drug should be limited in patients with kidney or liver disorders.
Possible Side Effects:
Headache, Flushing, Indigestion, Nasal congestion, Muscle aches
Back pain, Vision distortion, Priapism has been rarely associated with oral
medications. (A persistent abnormal erection that is usually with no sexual
desire and lasts for longer than several hours requires immediate medical
attention.)
The FDA ordered further studies and a precaution for oral ED medications
which may have been associated with non-arteritic anterior ischemic optic
neuropathy (NAION). NAION is caused by sudden vision loss when blood
flow to the optic nerve is blocked, and may lead to blindness. NAION
was found in association with disease states such as hypertension and
diabetes, diseases often associated with ED as well.
12 – ED: A Patient Quick-Guide to Cause, Diagnosis & Treatment
SELF-INJECTION
Self-injection involves using a short
needle to inject medication through
the side of the penis directly into the
corpus cavernosum, which produces
an erection that lasts from 30 minutes
to several hours. Vasoactive drugs
Medication is injected into
include muscle relaxants, papaverine,
the upper end of each of
alprostadil (prostaglandin), and
the cavernosa.
phentolamine. They cause vascular
dilation and a relaxation of smooth muscle. Alprostadil is the only substance currently FDA approved for erectile dysfunction treatment.
Possible Side Effects:
Common side effects include bruising at the injection site and Priapism.
Rarer complications are infection,bleeding,dizziness,and heart palpitations.
Repeated injection may cause scarring of erectile tissue, which can further
impair erection.
URETHRAL SUPPOSITORIES
Urethral suppositories containing alprostadil,
may be an alternative to injection. Using a handheld delivery device, a man inserts an alprostadil
pellet through the meatus (penis opening) into
the urethra. Alprostadil is absorbed through
the urethral mucosa and into the surrounding
erectile tissue. It is available with a prescription,
is well tolerated, and may improve erections in
60% of men who use it.
Possible Side Effects:
Penile Pain, Irritation of the Urethra, Priapism
A simple device places
a pellet in the urethra.
ED: A Patient Quick-Guide to Cause, Diagnosis & Treatment – 13
PENILE IMPLANTS
Penile implants involve surgical insertion
of malleable or inflatable rods or tubes
into the penis.
A semi-rigid prosthesis is a silicon-covered
flexible metal rod.Once inserted,it provides
the rigidity necessary for intercourse and
can be curved slightly for concealment. It
requires the simplest surgical procedure
of all the prosthesis. Its main disadvantage
is that concealment can be difficult with
certain types of clothing.
Malleable Prosthesis
An inflatable penile prosthesis consists of
two soft silicone or bioflex (plastic) tubes
inserted in the penis, a small reservoir
implanted in the abdomen, and a small
pump implanted in the scrotum. To
produce an erection, a man pumps sterile
liquid from the reservoir into the tubes by
squeezing the pump in the scrotum. The
(3-Piece Prosthesis)
2-Piece
Prosthesis Available
tubes act as erectile tissue and expand to
form an erection. When the erection is no
longer desired, a valve allows the fluid to return to the fluid storage space.
Inflatable prosthesis are the most natural feeling of the penile implants
and they allow for control of rigidity and size.
Surgery, to insert a penile implant should only be performed in rare
situations. When a man fails to succeed with other treatments, an implant
is the last resort. Of all the treatments available, this one carries the most
irrevocable consequences.
Possible Side Effects:
Mechanical failure, Infection, Erosion, Migration, Intractable pain, Auto
inflation
14 – ED: A Patient Quick-Guide to Cause, Diagnosis & Treatment
ADDITIONAL RESOURCES
1. American Urological Association - http://www.auanet.org
2. Journal of Urology - http://www.jurology.com
3. WebMD - http://www.webmd.com
4. UsTOO - Prostate Cancer Education and Support Network
http://www.ustoo.org
REFERENCES:
Whitehead and Klyde, Clinical Geriatric Medicine 1990, 6:771-795
1
2 Tengs To
and Osgood, “The link between smoking and impotence: two decades of
evidence.” Preventive Medicine 32: 447-52, 2001.
3 Benet AE and Melman A, “The epidemiology of erectile dysfunction” Urol. Clin. N Am,
22;699-709, 1990.
4 Lewis, R. W. et al “Definitions, Classification, and Epidemiology of Sexual
Dysfunction,” Sexual Medicine: Sexual Dysfunction in Men and Women, Health
Publications, 2004
5 Feldman H.A., Goldstein I, Hatzichristou, D.G., Krane R.J. and McInlay J.B., “Impotence
and its medical and psychosocial correlates: results of the Massachusetts Male
Ageing Study,“ Journal of Urology 151:54-61, 1994.
6 Wei M, Maceraca, R.A., Davis D.R., Hornung C.A., Nankin H.R., Blair S.N., “Total
cholesterol and high density lipoprotein cholesterol as important predictors for
erectile dysfunction,” American Journal of Epidemiology 140:930-937, 1994.
7 Stanford J.L., Feng Z., Hamilton A.S., Gilliland F.D., Stephenson E.A., Eley J.W.,
Albertson P.C., Harlan L.C., Potosky A. L., “Urinary and sexual function after radical
prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes
Study.” Journal of the American Medical Association 283:354-360, 2000.
8 Catalona W. J., Carvahal G. F., Nager D.E., Smith D.S., “Potency, continence and
complication rates in 1,870 consecutive radical retropubic prostatectomies.” Journal
of Urology 162:433-438, 1999.
9 Goldstein I., Feldman M.I., Deckers, P. J., Babayan R.K., Krane R. J., “Radiation associated impotence: a clinical study of its mechanism.” Journal of the American
Medical Association 251:903-910, 1984.
10 Leliefield H.H.J., Stoevelaar H.J., McDonnell J.M., “Sexual function before and after
various treatments for symptomatic benign prostatic hyperplasia.” British Journal of
Urology International 89:208-213, 2002.
11 Derby P.A., Barbour Hume A.L. and McKinlayu, J.B., “Drug therapy and prevalence of
erectile dysfunction in the Massachusetts Male Cohort.” Pharmacotherapy 21:676 683, 2001.
12 The Cleveland Clinic, at http://www.webmd.com/content/article/57/66229.htm
13 Benet A.E. and Melman A., “The epidemiology of erectile dysfunction.” Urol. Cinic. N
Am. 22: 699-709, 1995.
14 Laumann E. O., Paik A., Rosen, C., “Sexual dysfunction in the United States: Prevalence
and prediction.” Journal of the American Medical Association 281:537-544, 1999.
ED: A Patient Quick-Guide to Cause, Diagnosis & Treatment – 15
NOTES
16 – ED: A Patient Quick-Guide to Cause, Diagnosis & Treatment
Funding for Erectile Dysfunction: A Patient Quick-Guide to Cause, Diagnosis & Treatment
is provided by a grant from the Research & Education Center of Augusta Medical Systems, LLC,
the developer of SomaTherapy-ED®, The New Generation of Vacuum Therapy Systems for ED.
1025 Broad St, Augusta, GA 30901, 800-827-8382, www.augustams.com
Copyright ©2006 Charter Publishing
PQG V. 10/07